366426055-8-14-2023-56-AS-NBRN-CV2TJV-20230825144659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366426055
Report Date: 08/14/2023
Date Signed: 08/14/2023 01:20:56 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2023 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230807153844

FACILITY NAME:	BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)		FACILITY NUMBER:	366426055
ADMINISTRATOR:	MARGUERITE CROCKEM		FACILITY TYPE:	740
ADDRESS:	28807 BASELINE STREET		TELEPHONE:	(909) 742-7353
CITY:	HIGHLAND	STATE: CA	ZIP CODE:	92346
CAPACITY:	115	CENSUS:	DATE:	08/14/2023
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Marguerite Crockem - Executive Director		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff did not apply ointment as prescribed.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the investigation of and deliver findings on the above complaint allegation. LPA met with Mrs. Crockem. The investigation included interviews with resident and staff and records review.

It is alleged that Staff did not apply ointment as prescribed. LPA reviewed records and found that Resident 1 (R1) was first seen on 12/26/22 for a rash an nonspecific skin eruptions. Witness and staff interviews confirmed that R1 continued to have skin issues throughout and was last seen on 07/15/23 and treated for scabies. LPA reviewed medication records and found scabies medication Permethrin cream was administered on 07/28/23 through 07/30/23 and 08/3/23 through 08/5/23. While staff interviewed stated that the cream is administered one time every two weeks, recorded administration of the cream does not follow the two week schedule. Furthermore, LPA interviewed R1 who is able to verbalize their needs. Review of medication record further reveal that as needed medication for rash or itching was not administered. LPA found that allergy medication for itching was started on 7/16/23 and administered only on 8/11/23 through the end of this report.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/07/2023 and conducted by Evaluator Anna Bueno

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20230807153844

FACILITY NAME:	BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)		FACILITY NUMBER:	366426055
ADMINISTRATOR:	MARGUERITE CROCKEM		FACILITY TYPE:	740
ADDRESS:	28807 BASELINE STREET		TELEPHONE:	(909) 742-7353
CITY:	HIGHLAND	STATE: CA	ZIP CODE:	92346
CAPACITY:	115	CENSUS:	DATE:	08/14/2023
		UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Marguerite Crockem - Executive Director		TIME COMPLETED:	01:25 PM

ALLEGATION(S):

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Staff did not bathe resident.
Staff does not keep resident’s room clean.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Anna Bueno conducted an unannounced visit to the facility to initiate the investigation of and deliver findings on the above complaint allegation. LPA met with Mrs. Crockem. The investigation included interviews with resident and staff, facility observations, and records review.

Allegation 1: Staff did not bathe resident (R1). LPA observed R1 with skin breakdown on their arms but appeared groomed and in clean clothes. Interview with R1 stated that their hair was washed today. LPA reviewed records showing that R1 receives shower assistance twice weekly. Staff interviews confirm that resident assistants who assist R1 with showers first reported to med techs of R1's skin condition. This allegation is unsubstantiated.

Allegation 2: Staff does not keep resident’s room clean. LPA observed R1's room to be tidy with observable white specks on the floor. LPA reviewed records and witness interviews acknowledge that R1 has a skin condition causing flaking. Records reviewed and staff interviews reveal that R1's room is cleaned once weekly and R1's laundry is washed by resident assistants twice a week. This allegation is therefore unsubstantiated.

A finding of UNSUBSTANTIATED means, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. An exit interview was conducted with executive director Marguerite Crockem where a copy of this report was provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 56-AS-20230807153844

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)	FACILITY NUMBER: 366426055
	VISIT DATE: 08/14/2023

NARRATIVE

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Based on the information obtained during the investigation, this agency has substantiated the complaint allegation as valid and that a violation has occurred based on the preponderance of available evidence. This poses a potential health and safety risk to client in care. Refer to LIC9099-D for deficiency cited.

An exit interview was conducted and a copy of this report, LIC9099-D, and appeal rights were provided to Executive director Marguerite Crockem.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 56-AS-20230807153844

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: BRIGHTWATER SENIOR LIVING OF HIGHLAND (DBA)	FACILITY NUMBER: 366426055
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/14/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/31/2023 Section Cited CCR 87465(b)	1 2 3 4 5 6 7	(b) If the resident's physician has stated in writing that the resident is able to determine and communicate his/her need for a prescription or nonprescription PRN medication, facility staff shall be permitted to assist the resident with self-administration of his/her PRN medication.	1 2 3 4 5 6 7	Facility shall conduct a medication audit, specifically for creams and medication applied topically. Medication Technician training review to be completed and in-service record to be submitted to the DEpartment no later than end of POC date.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: LPA reviewed R1 medication administration records that are not the same as the medical order. Records further reveal that R1 was administered allergy medication for itching once on 08/11/23	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna Bueno	TELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:	DATE: 08/14/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2023

LIC9099 (FAS) - (06/04)

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